Review Question - QID 104440

This patient is presenting with a fever, chest pain, odynophagia, a Hamman crunch on exam, and a CT demonstrating a mediastinal infection which is concerning for mediastinitis. This probably is a sequelae of a dental infection in a patient with poor follow up/care.

The most dreaded complication of a retropharyngeal abscess involves spread of the infection into the mediastinum. This can start as a dental infection that spreads to Ludwig angina (submandibular erythema, dysphonia, and dysphagia) which subsequently forms an abscess that can track into the mediastinum. It can also occur after surgery that enters the mediastinum. As a consequence of fascial planes in the neck, the retropharyngeal space is continuous with the mediastinum. This communication results in the potential for infection of this space to spread into deeper areas (including the mediastinum) with disastrous consequences. Physical exam may demonstrate a Hamman crunch which is a crunching and rasping sound that is synchronous with the heartbeat. The diagnosis can be supported by a CT; however, unstable patients should not receive a CT scan. Emergent exploration and drainage is required when this diagnosis is made in addition to broad-spectrum antibiotics.

Figure/Illustration A is a CT scan demonstrating gas/inflammation which could be seen in mediastinitis (red arrow). Figure B is an ECG demonstrating sinus tachycardia.

Incorrect Answers:
Answer 1: Esophageal rupture would present with odynophagia, palpable crepitus, and possibly an amylase positive pleural effusion after profuse vomiting. The diagnosis can be supported with a Gastrografin swallow and treatment involves broad-spectrum antibiotics and surgical repair.

Answer 2: Ludwig angina is typically a progression from a dental infection and is a rapidly spreading cellulitis with potential for airway obstruction and abscess formation. This condition is often an airway emergency and requires broad-spectrum IV antibiotics and surgical intervention. If the infection spreads further, it can cause mediastinitis.

Answer 4: Myocardial infarction presents with chest pain, dyspnea, ST elevation (in a STEMI with an elevated troponin) or no ST elevation (with elevated troponins) in an NSTEMI. This patient's elevated troponin is likely demand-based ischemia coupled with poor renal clearance given his elevated creatinine.

Answer 5: Pulmonary embolism presents with chest pain, hypoxia, and a visible thrombus in the pulmonary vasculature. Troponins can be elevated in this condition as can the BNP given the heart strain from an obstructing thrombus. Treatment involves heparin or TPA in a massive pulmonary embolism.

Bullet Summary:
Mediastinitis presents with chest pain, odynophagia, Hamman crunch, and a fever with signs of infection on CT.